2-stage reimplantation for infected total knee replacement

Between 1977 and 1983, 64 infected total knee replacements in 60 patients were treated with a 2-stage protocol for reimplantation. The clinical results and survivorship were determined at an average followup of 7.5 years (range, 2-17 years). Surgical protocol included removal of the prosthesis and all cement with thorough debridement of bone and soft tissues. This was followed by 6 weeks of parenteral antibiotics and then reimplantation of a new prosthesis. At followup, 6 knees (9%) had become reinfected, but only 2 with the same organism. Four knees had been revised: 3 for aseptic loosening and 1 for a periprosthetic femur fracture. Two other knees were impending failures due to aseptic loosening. The average Hospital for Special Surgery knee score was 78 points with 18 excellent, 28 good, 13 fair, and 5 poor results. Seventy-eight percent of patients were satisfied with the overall result of their reimplanted prosthesis and 95% think that they made the right decision in undergoing total knee arthroplasty. The 10-year predicted survivorship of 2-stage reimplantation is 77.4%. Two-stage reimplantation with a 6-week course of parenteral antibiotics is an effective means to eradicate deep infection and to provide a functional knee. The long term functional results and overall survivorship are comparable with the results of revision of aseptic failed total knee arthroplasty.     

Surgical management of osteochondritis dissecans of the capitellum

Ten cases of osteochondritis dissecans of the humeral capitellum which were treated surgically are reviewed. All 10 cases were males and involved the dominant side. The ages at surgery ranged from 13 to 17 years. Follow-up ranged from 1 to 7 years. All of the youths had competed in organized athletics, either baseball or football. By position there were three pitchers, two catchers, two infielders, and one outfielder; in addition there were one quarterback and one linebacker. Only one patient presented with locking of the elbow, whereas the others presented with pain and limitation of extension. The locked elbow was explored immediately and the others were explored after immobilization failed to relieve their symptoms. In seven of the joints a loose fragment of the capitellum was found lying either in the joint or in a defect in the capitellum. The fragment had multiple small holes. In three cases there was no loose fragment. In this situation a corticol window was cut above the capitellum. The capitellum was then drilled and bone was grafted from above. Over all, there were one excellent, six good, one fair, and two poor results. There seemed to be little difference between curretting alone or curetting and drilling. The cases with the cartilage intact and bone grafted from above did worse, with one fair and one poor result of three cases. The two poor results required further surgery, which consisted of partial excision of the capitellum. All cases lacked elbow extension before and after surgery, but nine of 10 gained some motion after surgery. Pre- and postoperative x-rays are shown in this report and a brief review of the literature concerning osteochondritis dissecans is presented.     

Arthroscopic treatment of cysts of the lateral meniscus

We have treated 69 patients with 72 cystic lateral menisci by arthroscopic surgery. Meniscal tears were observed in all cases, and 69 of these had a horizontal cleavage component. Three types of tear were identified and may be progressive. Treatment was by arthroscopic resection of the meniscal tear, and decompression of the cyst through the substance of the meniscus. After a mean follow-up of 34 months the results were good or excellent in 64 knees (89%) and there were few complications. We recommend this technique as the treatment of choice for cysts of the lateral meniscus.     

Neuroma of the sural nerve as a complication of stripping of the small saphenous vein

From 1989 to 1996, 61 patients, including 66 knees, aged 8 to 62, were diagnosed as mediopatellar plica syndrome of knee after arthroscopic examination. Twenty-one cases were misdiagnosed as medial meniscal lesions before arthroscopic examination. Fifty-nine patients (64 knees) underwent arthroscopic resection of the plicae and 2 patients underwent opened resection. Fifty-nine cases had an average follow-up of seven months. Fifty cases (54 knees) of them showed excellent and good results.     

Complications following total knee replacement

Forty-two months follow-up examinations on 30 total knee arthroplasties revealed the following significant complications: phlebothrombosis, 13 knees (46%); pulmonary embolism 3 patients (11%); asymptomatic loosening, 8 knees (11.4%); symptomatic loosening, 3 knees (4.8%); superficial infections, 4 knees (5.4%); deep infections, 4 knees (5.4%); peroneal palsy, 3 patients (4.3%). Early detection of thrombophlebitis by 125I fibrinogen scan and possible aspirin prophylaxis were evaluated. In view of the limited number of encouraging results, e.g. excellent 58.6 per cent; good 28.5 per cent; fair 5.4 per cent and poor 7.1 per cent, caution is advocated until extensive time elapses for more clinical experience with total knee arthroplasty.     

Mechanical distraction for treatment of severe knee flexion contractures

Ten patients (14 knees) with severe knee flexion contractures were treated by gradual mechanical distraction using either the Ilizarov or Orthofix external fixator. Range of motion improved from an average flexion contracture of 60 degrees before surgery to 16 degrees at the follow-up evaluation. Range of motion results were graded good or excellent in five knees, fair in two knees, and poor in three knees. Average total arc of motion remained essentially unchanged when comparing the preoperative (59 degrees) with the follow-up results (63 degrees). However, the functional position of this arc improved significantly. Problems encountered included a "rebound" phenomena after frame removal, with loss of the temporarily increased total arc of motion. The role of hamstring tenotomy and radical posterior knee release remains unclear.     

Vascularized iliac bone graft for treating avascular necrosis of the femoral head

BACKGROUND: Nontraumatic avascular necrosis of the femoral head (ANFH) is a common disorder causing disability of the hip joint. The means for optimally treating this disease are still controversial. In this study we evaluated the relatively new technique of vascularized iliac bone grafting for treating ANFH. METHODS: From March 1990 to March 1992, 17 hips (15 patients) with ANFH were treated using the vascularized iliac bone grafting technique in our hospital. The patients included 12 men and three women, with an average age of 38 years. Steinberg's classification was used to categorize the severity of hip disease. The clinical results were classified as excellent, good, fair and poor according to symptoms, hip function and roentgenographic changes after surgery. Life-table analysis was applied to assess graft survival and the log rank test was used to compare statistical differences between the steroid-related and nonsteroid-related groups. RESULTS: Cumulatively, 16 hips (14 patients), excluding one patient (one hip) lost to follow-up, were clinically evaluated for an average of 68 months. Among 12 hips at Steinberg stage II, eight progressed to stage IV, three to stage III and only one remained at stage II. Although most hips at stage II showed mild to moderate disease progression on plain radiography, 58% of the hips (7/12) that progressed to less than IVb showed good to excellent results. In the three hips at stage III, one progressed to stage IVa and two to stage V. In the two hips at stage IV, one remained at stage IV at final follow-up and the other was lost to follow-up. The steroid-related and nonsteroid-related groups did not differ with respect to clinical results. Both groups had 63% (5/8) good to excellent results (p > 0.05, log rank test). Only four hips were converted to prosthetic arthroplasties at final follow-up. Overall, 63% (10/16) of the hips had good to excellent results, 12% had fair results and 25% had poor results. Graft survival after seven years of follow-up was 63%. CONCLUSIONS: While treatment of ANFH still poses a challenge to orthopedic surgeons, the vascularized iliac bone grafting technique is a clinically acceptable option for treating the early stages of ANFH.     

Characteristics of impaired awareness after traumatic brain injury

The condylar constrained total knee arthroplasty was performed on 29 patients undergoing 33 procedures and were reviewed clinically and radiographically at an average follow-up of 5 years (range, 2-10 years). There were 21 women and 8 men. The average age at the time of surgery was 70 years (range, 32-84). Of the 16 knees that were revision total knee arthroplasties, 8 had a previous infected total knee arthroplasty, and 17 knees had severe deformities requiring the use of the condylar constrained prosthesis. The patients were rated according to the Knee Society clinical and radiological evaluation protocol. Measurements of femoral and tibial component position were obtained as well as femoral tibial angle, patella position, and cement bone radiolucencies. All clinical measurements were made by an independent physical therapist. Clinical results revealed an improvement from an average preoperative knee score of 38 points to an average postoperative score of 86 points. The clinical results for 19 (58%) knees were excellent, 8 (24%) had a good result, 1 (3%) was fair, 2 (6%) were poor, and 3 (9%) were failures. The patients' average functional levels increased from 24 to 58. The final average flexion was 96 degrees. Three knees have been revised (9%). One was revised for recurrent infection, one for periprosthetic fracture, and one for mechanical loosening of the tibial component. There were no other knees with evidence of radiologic loosening. We conclude that the condylar constrained total knee prosthesis provides an acceptable solution for revision and complex primary total knee replacements at an intermediate follow-up term of 5 years.     

Intraarticular dexamethasone in advanced chronic synovitis in hemophilia

From 1988 to 1966, 34 patients with advanced chronic hemophilic synovitis (25 Grade III and nine Grade IV) were treated with intraarticular injections of long acting dexamethasone (sodium phosphate of dexamethasone plus acetate of dexamethasone) in cycles of three injections with 3-week intervals between each injection with 6-month rest intervals between cycles for as many as three cycles, depending on the evolution of each case. All patients had chronic severe synovitis, axial deformity, muscular atrophy, and diminution of range of movement. There were 31 knees, two ankles, and two shoulders. Subjective and objective evaluations were done grouping the results in good, fair, and poor according to grade of patient satisfaction, presence of synovitis and pain, range of movement, and limitation of activities of daily living. In the subjective results there were 19 good results, 12 fair results, and four poor results, and in the objective evaluation there were 22 good results, nine fair results, and four poor results at an average followup of 1.5 years. The use of intraarticular dexamethasone as an alternative in the short to medium term for treatment of advanced chronic hemophilic synovitis with pain and limitation of function before doing an invasive surgical treatment is proposed.     

Defects of pars interarticularis in athletes: a protocol for nonoperative treatment

The purpose of this study was to report the results of a specific treatment protocol for athletes with spondylolysis or spondylolisthesis of the lumbar spine. A retrospective study with recent follow-up was performed on 82 patients treated with restriction of activity, bracing, and physical therapy. All of the patients were involved in sports at first onset of symptoms. Sixty-six patients were boys and 16 were girls. Activities involving repetitive hyperextension and/or extension rotation of the lumbar spine were described as painful in 98% of the patients. Of the 62 patients with spondylolysis, 53 (85%) had an L5 defect and nine (15%) an L4 defect (90% of these 62 patients' defects were located in the most caudad mobile vertebra). Thirty-seven patients had bilateral pars defects, and 25 had unilateral defects. Eight patients had normal roentgenograms, but these eight had abnormal bone scans. Nine patients with spondylolysis underwent posterolateral fusion. Average follow-up was 4.2 years. Fifty-two (84%) had excellent results, eight had good results, and two had fair results. Twenty patients had a spondylolisthesis: 12 were grade I, six were grade II, and two were grade III. Twelve patients (60%) required surgery; 9 had excellent results, one had good results, one had a fair result, and one had a poor result. Pars defects must be suspected in the differential of low back pain in young athletes. Oblique radiographs are frequently diagnostic; however, if the history and examination are suggestive despite normal plain films, a bone scan should be obtained. Nonoperative management of pars defects is frequently successful.(ABSTRACT TRUNCATED AT 250 WORDS)     

Core decompression for avascular necrosis of the distal femur: long term followup

Seventy-nine knees (45 patients) with a diagnosis of avascular necrosis of the distal femur treated between 1978 and 1989 were evaluated. All patients had a corticosteroid association (had been treated with >30 mg of prednisone for >2 weeks predating by at least 6 months the onset of avascular necrosis). Thirty-two knees were managed with protected weightbearing and rest. Core decompression was performed at a minimum of 3 months after the onset of symptoms in another 47 knees. The knees treated with protected weightbearing had an average asymptomatic period of only 11 months and all but 6 (18%) proceeded to total knee replacement within 6 years. Core decompression yielded good or excellent results in 73% of the knees at an average followup of 11 years (range, 4-16 years). Of the 13 knees with failed core decompression, 7 were asymptomatic for greater than 5 years. A subset of 26 knees from each group was matched for age, gender, diagnosis, Ficat and Arlet Stage, and length of followup. The matched noncore group had 23% survival as compared with 74% survival in the core group. This long term followup suggests that core decompression may slow the rate of symptomatic progression of avascular necrosis of the knee. In addition, core decompression may extend the symptom free interval in certain patients and may delay the need for more extensive procedures such as total knee arthroplasty.     

Arthroscopic extra-articular Bankart procedure

The arthroscopic extraarticular Bankart procedure tries to imitate the open Bankart procedure. An anterior-inferior transmuscular approach through the subscapular muscle permits to implant self-locking tacks into the anterior inferior third of the glenoid rim. The extraarticular location of the implants makes a superomedial capsular shift possible, if required. A total of 257 arthroscopic repairs following traumatic recurrent anterior shoulder dislocation have been carried out between 1992 and 1996. 177 patients were treated only with bioabsorbable Suretac device. Clinical and radiological follow up was possible in 165 patients. According to the Rowe score 69.7% were classified as excellent, 10.9% as good, 9.7% fair and 9.7% poor. Postoperative complications: the recurrence rate was 9.7%, allergic reactions representing a foreign body reaction to the synthetic material were seen in 5 cases (3%) and a frozen shoulder in 6 cases 3.6%). 61% of the patients involved in overhead or contact sports returned to their preoperative sport activities.     

Structural and functional analysis of gp64, a membrane protein of the cellular slime mold Polysphondylium pallidum

We examined 38 patients with an arthroscopic bioabsorbable tack repair for anterior shoulder instability in a prospective evaluation. The mean follow-up was 22 months (range 12 to 33). The average age was 28.4 years (range 15 to 57), the operation was performed at average of 50 months (3 to 244 months) after injury. Assessment using the Rowe score revealed excellent results in 33 and good results in 3 patients. 1 patient had a fair result and 1 had a poor result. 26 should obtained full range of motion, 11 had minor (< 10 degrees) loss of external rotation, 1 experienced greater (< 20 degrees) loss of external rotation. 3 of the 38 patients (8%) had recurrent instability, 1 patient with 2 preceding operations and atraumatic and voluntary dislocation, respectively. The recurrence rate of arthroscopic Bankart repair with bioabsorbable tacks are comparable to open Bankart procedures. Success of the procedure depends on appropriate surgical technique and suitable selection of patients with unidirectional, posttraumatic, anterior instability who are found to have well-developed ligamentous tissue.     

Intraarticular anatomic variants associated with discoid meniscus in Koreans

From July 1990 through June 1994, 106 knees (102 patients) were treated for discoid meniscus. Fifteen knees (15 patients) were associated with other intraarticular anatomic variants. There were eight knees (8 patients) with anomalous insertion of the anterior horn of the medial meniscus into the anterior cruciate ligament, and seven knees (7 patients) with anterior expansion of the anterior portion of the anterior cruciate ligament below the anterior tibial margin. Among the latter, one patient also had anterior transposition of the anterior insertion of the medial meniscus, while obliteration of the popliteal hiatus was seen in another patient. The discoid menisci were reshaped in 13 knees (13 patients), totally resected in one knee, and in one patient the discoid meniscus was treated with repair of a peripheral tear and reshaping. Followup ranged from 24 to 54 months (average, 37 months) after surgery. The results were excellent in eight knees, good in five knees, and fair in two knees as graded using the Ikeuchi scale. These anatomic variants, other than the discoid meniscus, did not seem to be related to the patient's symptoms.     

Aspiration of the knee joint before revision arthroplasty

Sixty-four operative procedures were performed on 55 patients with knee arthroplasties for pain, loosening, instability, or suspicion of infection. Forty-three knees had a preoperative aspiration. In 19 knees, the aspiration showed growth on solid media, and in 18 of these knees the diagnosis of infection was confirmed by the intraoperative cultures. In 1 knee with an infected total knee replacement, the patient was receiving an intravenous antibiotic at the time of arthroscopic irrigation and debridement and the cultures showed no growth. In 23 of 24 knees with a negative preoperative aspiration, the intraoperative cultures showed no growth on solid media. In 1 knee with a preoperative aspiration that had negative results, a single intraoperative culture grew Staphylococcus epidermidis. However, the presenting symptoms, examination, preoperative radiographs, and intraoperative evaluation were consistent with aseptic loosening of a cemented total knee arthroplasty. Thus, the preoperative aspiration of the prosthetic knee joint had a sensitivity of 100%, specificity of 100%, and accuracy of 100%. The Westergren erythrocyte sedimentation rate, peripheral leukocyte count, and presenting symptoms correlated poorly with infection. Radiographs were also not helpful in the diagnosis of infection, with loosening of components, periostitis, focal osteolysis, and radiolucent lines frequently seen in infected and noninfected knees. Preoperative aspiration of the knee is the most helpful study for the diagnosis or exclusion of infection in a prosthetic knee joint.     

Osteonecrosis of the femoral head. Hip salvaging with implantation of a vascularized fibular graft

The authors tried to save the hip joint by implanting a vascularized fibular graft, augmented with cancellous bone, into the curetted core of the femoral head that was affected by aseptic necrosis. Forty of 66 hips were observed for a minimum of 20 months and for as long as 66 months (average, 32 months). Clinical assessment according to the cause and severity of the disease was done using the Harris Hip Score. Twenty-eight hips (70%) were rated excellent, 7 (17.5%) were good, 2 (5%) were fair, and 3 (7.5%) failed and were replaced with an artificial joint. Clinically satisfactory results, including good and excellent, were obtained in 35 hips (87.5%). Radiographic evaluation showed improved appearance of the femoral head core in all 15 patients (37.5%) operated on at a precollapse stage of the disease. In 20 hips, the deformity of the femoral head was unchanged (50%), 2 (5%) became worse, and 3 (7.5%) failed. The number of hips with improved appearance as shown on radiographs and those in which the process was unchanged equaled the number of hips with satisfactory clinical results. These data show that the procedure can induce new bone formation that fuses with the affected subchondral bone, thus preventing the articular surface from collapse. This suggests that vascularized fibular grafting is an excellent alternative for hip salvaging when treating femoral head osteonecrosis.     

Cervical disk disease and the keyhole foraminotomy: proven efficacy at extended long-term follow up

Eighty-four consecutive patients with posterolateral cervical disk herniation treated by keyhole foraminotomy between 1980 and 1987 were reviewed. Radicular pain was the most common presenting complaint. Weakness was present in 59 patients. Sixty patients were available for long-term follow up, averaging 6.1 years. Fifty-six patients' results were graded as excellent. Three patients had good results and one fair result was noted. There were no poor results. Preoperative pain symptoms were relieved in all patients. There were no significant complications. The posterolateral keyhole foraminotomy is an efficient means of decompressing lateral soft disk herniations, without the risk of an anterior approach or iliac crest bone harvest. Careful patient selection and use of an operative microscope are essential in obtaining consistent, excellent results.     

Selenium-based antihypertensives. Rationale and potential

We carried out percutaneous, arthroscopically- and fluoroscopically-assisted osteosynthesis of fractures of the tibial plateau in 52 patients, of whom 38 were assessed using the HSS knee score and standing radiographs. We reviewed 31 AO type-B fractures and seven type-C fractures after a mean follow-up of five years (1 to 14). Fixation was achieved using percutaneous screws and/or an external frame; 33 associated intra-articular injuries, diagnosed in 21 out of the 38 patients, were treated arthroscopically. Subjectively, 94.7% of the patients reviewed were satisfied. According to the HSS knee score 78.9% of the results were excellent, 13.2% good, 7.9% fair and none was poor. Narrowing of the joint space was found in 28.9% of the injured and 5.3% of the unaffected knees and axial deviation of 5 degrees to 10 degrees in 15.8% of the injured and 10.5% of the unaffected knees. Of the 52 fractures, reduction was incomplete in one, and in two secondary displacement occurred, of which one required corrective osteotomy. Deep-venous thrombosis occurred in four cases. The technique has proved to be safe but demanding. It facilitates diagnosis and appropriate treatment of associated intra-articular lesions.     

The prevalence and related symptomatology of Helicobacter pylori in children with recurrent abdominal pain

The plicae are synovial septa remaining in adult life that existed in early fetal life. The suprapatellar plica separates the suprapatellar pouch from the knee joint. The plica syndrome has clinical significance, which has been occasionally overlooked, but the pathophysiology of symptomatic plicae may be hard to explain. To evaluate the clinical significance of the suprapatellar plicae, the authors reviewed 34 cases in 23 patients with vague pain around the knee and a total septum of the suprapatellar plica at arthroscopic examination from September 1991 to December 1993. The follow-up period was from 6 months to 2 years and 9 months. The most common presenting symptom was chronic mild knee pain, aggravated by prolonged squatting or standing, with other patients reporting recurrent swelling, instability, giving-way, or a feeling of snapping. The objective findings include palpable band on the superomedial side, audible snapping, and local tenderness, but there were no significant abnormal findings in the laboratory. The radiographic findings were few, with sclerosis of the articular surface of the patella in 2(6%), malalignment in 1(3%), and mild degenerative change in 4 cases(12%). Five of 11 patients evaluated by bone scan had increased uptake around the patellofemoral joint, and 7 of 13 knees had a relatively small suprapatellar bursa on conventional arthrogram or pneumoarthrogram. At arthroscopy, a suprapatellar plicae with complete septum was identified in 30 of 34 cases (88%) and associated lesions presented as meniscal tears, loose body, and discoid meniscus without tear. The complete plicae were surgically excised under arthroscopic control in 30 patients and the results were excellent in 22 patients (73%), good in 5 (17%), and poor in 3 (10%)at 17 months follow-up; there were no failures. In our opinion, the complete suprapatellar plica is clinically significant in patients who have equivocal diagnosis of knee problems and further studies of the pathophysiology of complete suprapatellar plica are needed.     

Displaced fractures of the glenoid fossa. Results of open reduction and internal fixation

Displaced fractures of the glenoid fossa are an uncommon and anatomically diverse group of injuries. Failure to restore anatomy in these fractures results in poor outcome in most cases. The success of a treatment protocol that encompasses appropriate preoperative imaging, injury pattern assessment, prudent approach choice, and a comprehensive reduction and fixation tactic was evaluated. Twenty-seven patients were assessed clinically and radiographically at a mean followup interval of 43 months from surgery. Anatomic reconstruction was achieved in 24 (89%) patients. Three patients had residual joint incongruities measuring 2 mm or less. The only perioperative complication was a partial superficial wound dehiscence. Two additional patients had infraspinatus palsies of indeterminate origin. Functional rating revealed six (22%) excellent, 16 (60%) good, three (11%) fair, and two (7%) poor outcomes. The fair and poor outcomes largely were related to associated injuries. These findings show that anatomic surgical reconstruction with a low complication rate and good functional outcome can be obtained for most patients with glenoid fossa fractures.